Infections of head and neck

Space infections

1. O dontogenic infections of head and neck PRESENTED BY: DR MOHAMMED HANEEF

2. Index Introduction Classification of infection Stages of infection Microbiology of odontogenic infections Management of odontegic infections Classification of fascial planes Progression of infection Space infections of maxilla Space infections of mandible Space infections of neck Principles of treatment Management Refrences

3. Introduction Potential or actual space between fascia and muscles containing nerves, blood vessels and connective tissue but this becomes pathway of infection in presence of infection Infection may be defined as   invasion and multiplication of microorganisms in body tissues, especially that causing local cellular injury due to competitive metabolism, toxins, intracellular replication, or antigen-antibody response Fascial space infections are a relatively common presentation to both general medical and dental practitioners. Infections originating in deeper structures can be severe, rapidly progressive and may cause prolonged morbidity, long term complications as well as potentially endanger life.

4. Classification of infections According to the clinical appearance: Acute infections Chronic infections Acute exacerbation of a chronic infection Depending on the etiological agent: Bacterial Viral Fungal According to source of infection: Odontogenic Secondary infections of lesions such as cyst or tumors Infections arises from contaminated wound/trauma Iatrogenic infections

5. Stages of infections Stage I: Initiation of infection Mostly odontogenic in origin, Periapical /periodontal/ pericoronal infection Mildly symptomatic or asymtomatic . Stage II: Entry of infection in medullary bone Symptomatic, patient seeks treatment Tender on percussion No space for pus to drain starts effecting the medullary bone Stage III: Path of drainage Pus follow path of least resistance Perforates cortex that is thinner Appears in soft tissues, extra oral swelling May lead to cellulitis or abscess formation Stage IV: Spread of infection Spreads to another space along anatomical barriers May perforate the skin to form sinus

6. Microbiology of odontogenic infections Bacterial composition 5%-aerobic bacteria 60%-anaerobic bacteria 35% mixed aerobic and anaerobic bacteria Commonly cultured organisms: alpha-hemolytic Streptococcus, Peptostreptococcus , Peptococcus , Eubacterium , Bacteroides ( Prevotella ) melaninogenicus , and Fusobacterium . Quantitative estimations of the number of microorganisms in saliva and plaque range as high as 10 11 /ml.

7. Microbiology – aerobic Gram-positive cocci 85% Streptococcus spp. Streptococcus (group D) spp. Staphylococcus spp. Eikenella spp. Gram-negative cocci ( Neisseria spp.) 2% Gram-positive rods ( Corynebacterium spp.) 3% Gram-negative rods ( Haemophilus spp.) 6% Miscellaneous and undifferentiated 4%

8. Microbiology- Anaerobic Gram-positive cocci 30% Streptococcus spp. Peptostreptococcus spp. Staphylococcus spp. Gram-negative cocci ( Veillonella spp.) 4% Gram-positive rods 14% Eubacterium spp. Lactobacillus spp. Actinomyces spp. Clostridia spp. Gram-negative rods 50% Bacteroides spp. Fusobacterium sp.

9. Management of odontogenic infections Determine the severity of the infection Complete history Physical examination State of the patients host defense Treat the infection surgically Support the patient medically Choose the appropriate AB Re-evaluate the patient frequently

10. Severity of infection How the patient feels Previous treatment Self treatment Past Medical History Complete History Chief Complaint Onset Duration Symptoms

11. Clinical presentation History-previous toothaches (onset, duration), presence of fever, and previous treatments (antibiotics ) important Patients may complain of trismus , dysphagia and have shortness of breath should be investigated. Findings vary from mild swelling and pain to life-threatening airway compromise and CNS impairment

12. Inspection, palpation, and percussion are integral parts of the exam Begin extraorally and then move intraorally Skin of the face, head, and neck for swelling, erythema , sinus or fistula formation. Assess for cervical lymphadenopathy and fascial space involvement Assess for the presence and magnitude of trismus

13. Examine quality and consistency: Soft to fluctuant (fluid filled) to hard ( indurated ) Normal vs abnormal tissue architecture: Distortion of mucobuccal fold Soft palate symmetric with uvula in midline (deviation → involvement of lateral pharyngeal space) nasolabial fold, circumorbital areas

14. Identify causative factors: Tooth, root tip, foreign body, etc. Vital signs should be taken: Temperatures > 101 to 102 °F accompanied by an elevated heart rate indicate systemic involvement of the infection and increased urgency of treatment.

15. Imaging studies can further substantiate diagnosis – Panorex , Plain Films , CT , MRI Computerized tomograms should be obtained when infection has spread into fascial spaces in the orbit or neck Infections, well-localized to oral cavity do not require special imaging studies with a panorex being sufficient for diagnosis and treatment

16. Host – Defense mechanisms Local defenses Intact anatomic barrier Indigenous bacteria Humoral defenses Immunoglobulins Complement Cellular defenses Phagocytes Lymphocytes

17. Medically compromised patients Uncontrolled metabolic diseases Diabetes Alcoholism Malnutrition Suppressing diseases Leukemia Lymphoma Malignant Tumors Suppressing drugs Chemotherapeutic agents Immunosuppressives

18. One of the most common & difficult problems Range from low-grade to severe, life-threatening Most are easily managed with minor surgery and antibiotics

19. Common types of infection: Periapical , periodontal, postsurgical, pericoronal May begin as well-delineated, self-limiting condition with potential to spread and result in a major fascial space infection. Life-threatening sequelae can ensue: Septicemia, cavernous sinus thrombosis, airway obstruction, mediastinitis

20. Progression of Odontogenic Infections Periapical Periodontal Soft tissue involvement Determined by perforation of the cortical bone in relation to the muscle attachments Cellulitis - acute, painful, diffuse borders Abscess- chronic, localized pain, fluctuant, well circumscribed.

21. Cellulitis : initial stage of infection Diffuse, reddened, soft or hard swelling that is tender to palpation. Inflammatory response not yet forming a true abscess. Microorganisms have just begun to overcome host defenses and spread beyond tissue planes.

22. True abscess formation As inflammatory response matures, may develop a focal accumulation of pus. May have spontaneous drainage intraorally or extraorally .

23. Differences between cellulitis & abscess Cellulitis Abscess Duration Acute Chronic Pain Severe generalized Localised Size Large Small Localization Diffuse borders Well circumscribed Palpation Doughy indurated Fluctuant Presence of pus No Yes Degree of seriousness Greater Less Bacteria Aerobic anaerobic

24. Classification of fascial spaces Based on mode of involvement Direct involvement (Primary spaces) – maxillary spaces , mandibular spaces Indirect involvement (Secondary spaces ) – Lateral pharyngeal space Based on clinical significance by Topazian Face – buccal , canine, masticatory , parotid Suprahyoid – sublingual, submandibular ( submaxillary , submental ) pharyngomaxillary (lateral pharyngeal) peritonsillar Infrahyoid – anterovisceral ( pretracheal ) Spaces of total neck – retropharyngeal, space of carotid sheath

25. BASED ON FASCIA Superficial fascia Deep cervical fascia Anterior layer Investing fascia ( over the neck) Parotidomasseteric Temporal Middle layer Sternohyoid - omohyoid division Sternothyroid - thyrohyoid division Visceral division – Buccopharyngeal Pretracheal Retropharyngeal Posterior layer Alar division Prevertebral division

26. According to Grodinsky & Holyoke in 1938 Space 1 – potential space superficial and deep to the platsyma muscle Space 2 – space behind the anterior layer of deep cervical fascia Space 3 – pretracheal space, ant to layer of deep cervical fascia Space 3A – viscerovascular space; is the carotid sheath from the jugular foramen and carotid canal at the base of skull to the pericardium ( lincoln’s highway) Space 4 – ‘Danger space’ potential space b/w alar and prevertebral fascia. Extends from base of skull to the prevertebral fascia Space 5 – it is the space enclosed by the prevertebral fascia posterior to transverse processes of vertebrae

27. According to killey and kay In relation to lower jaw: Submental Submandibular Sublingual Buccal Submassetric Parotid Pterygomandibular Lateral pharygeal Peritonsillar In relation to the upper jaw: Canine space Palatal space Maxillary antrum Infratemporal space Subtemporal space

28. SPACE OF BURNS : The Suprasternal Space The superficial fascia splits below the level of the hyoid bone to form 2 spaces - Forms lower part of the roof of the post triangle, the fascia splits into two layers, attached to clavicle - Forms lower part of the roof of the ant triangle and fascia splits to form the suprasternal space

29. Spaces involved in odontogenic infections Primary maxillary spaces – canine, palatal, and infratemporal spaces Primary mandibular spaces – submental , buccal, submandibular and sublingual spaces Secondary fascial spaces – masseteric , pterygomandibular , superficial & deep temporal, lateral pharyngeal, retropharyngeal, prevertebral , parotid

30. Maxillary Odontogenic Infections Canine space Palatal space Infratemporal space Subt emporal space

31. Canine space infection/ Infraorbital space infection This is a potential space present on the anterior surface of the maxilla in the region of canine fossa Appear commonly as labial sulcus swelling Levator anguli oris and levator labii superioris muscle overlies apex of canine root Origin: canine fossa . Insertion: angle of mouth

32. Boundries : superiorly: Levator angulii oris Levator labii superioris Posteriorly : Buccal space Inferiorly: Orbicularis muscle Contents: infrorbital nerve and its branches

33. Canine space infection Signs: Obliteration of the nasolabial fold Drooping of angle of mouth Superior extension can involve lower eyelid Open in relation to medial canthus of eye

34. Incision for canine space infection Intra-oral approach, high in labial vestibule by sharp and blunt dissection Percutaneous drainage – lateral to the nose

35. Differential diagnosis: Maxillary sinusitis Dacryocystitis

36. Palate is covered by tightly adherent mucoperiosteum Periosteum is tightly bound to the mucosa, periodontal membrane of the adjacent teeth and to the suture in the midline Pus tends to accumulate between periosteum and bone Infections begin in lateral incisor or upper post tooth It is in the subperiosteal space of palate Exquisitely painful due to rich innervations of the periosteum Palatal space infection

37. Signs and symptoms circumscribed fluctant swelling confined to one side May discharge from the gingival sulcus Infection does not cross midline Infection from: Upper lateral incisor Palatal pocket in premolars or molars Infection of palatal root

38. Management: Incision should be in AP direction to avoid injury to anterior palatine nerve Treatment of offending tooth Differential diagnosis: Extravasation cyst Gumma Pleomorphic adenoma Carcinoma of maxillary antrum

39. Infratemporal space infection Odontogenic infections of maxillary posterior teeth Odontogenic infections involving the pterygomandibular space or infection from buccal space coursing along the masticatory fat pad. Anatomical boundries : laterally: ramus of mandible, temporalis muscle and temporalis tendon Medially: lateral pterygoid plate Superiorly: infratemporal surface of the greater wing of sphenoid Inferiorly: lower head of lateral pterygoid muscle

40. Contents: Origin of pterygoid muscles Pterygoid venous plexus Internal maxillary artery Mandibular nerve and its branches Signs and symptoms: Infected upper molar teeth Severe trismus is universal finding extraoral swelling over the sigmoid notch, intra oral swelling in the tuberosity area

41. Management: Intravenous antibiotics Incision in upper buccal sulcus in third molar region Use of sinus forceps along medial surface of coronoid and temporalis upwards and backwards

42. Mandibular Space Infections Sublingual space Submental space Submandibular space Ludwigs angina Masticator space Lateral pharyngeal space Temporal space

43. Submental space Potential space present just below the chin region on the medial surface of the mandible It is a midline structure bordered laterally by the anterior bellies of digastric muscle Infections begin in the anterior mandibular teeth Secondarily Infected skin wounds or anterior mandibular fractures may also cause infections

44. BORDERS: Anterior – inf border of mandible Posterior – hyoid bone Superior – mylohyoid muscle Inferior – investing layer of deep cerical fascia Deep/Lateral - ant. bellies of digastric muscle Contents: Submental lymphnodes Anterior juglar veins Adipose tissue

45. Signs and symptoms: Firm circumscribed swelling beneath the chin Patient complains of discomfort and difficulty in swallowing Management: Incision is made bilaterally through the skin, subcutaneous tissue and platsyma muscle at the most inferior aspect of swelling A hemostat is inserted through one incision and then exited through the second incision

46. Incision for submental abscess

47. Sublingual space It is a potential space present in the anterior part of the floor of the mouth It almost always involved with submandibular space Only loose connective tissue separates right and left sublingual spaces and infection spreads easily from side to the other Boundries : Anteriorly and laterally– medial surface of mandible Posteriorly – submandibular space Superiorly – sublingual mucosa Inferiorly – mylohyoid muscle medially - genioglossus , geniohyoid , styloglossus muscles Superficial – muscles of tongue Deep – ant.bellies of digastric muscle

48. The styloglossus muscle passes b/w superior & middle pharyngeal constrictor muscles in this region to enter the tongue The seperation b/w these pharyngeal constrictors formed by the styloglossus muscle is termed BUCCOPHARYNGEAL GAP

49. Sublingual space Elevation of floor of mouth Tongue raised Respiratory difficulty

50. Incision is placed at the base of the alveolar process in the lingual sulcus so that the sublingual gland, lingual nerve & submandibular duct are not injured A hemostat is inserted through the incision in an ant & post direction & beneath the sublingual gland to evacuate the pus Incision for Sublingual space infection

51. Submandibular space It is a potential space present on the medial surface of the posterior aspect of the mandible Anatomical boundries : Anteriorly – ant. belly of digastric muscle Posteriorly - post. belly of digastric muscle, stylohyoid muscle, stylopharyngeus muscle Superior – inf & medial surfaces of mandible Inferior – digastric tendon Superficial – platsyma muscle, investing fascia Deep – mylohyoid , hypoglossus , sup constricting muscles Laterally – bounded by skin, superficial fascia, platysma Contents: Submandibular salivary gland Lymph nodes Facial artery Lingual and hypoglossal nerves

52. Submandibular space Triangular swelling Begins at the lower border of mandible, extends to level of hyoid bone Brawny induration Usually associated with lower molar infection

53. Two stab incisions are placed at the inf aspect of swelling in the shadow of the mandible Extended through the skin & superficial fascia Dissection is bluntly done through one incision with a curved hemostat, which is inserted through the platsyma muscle & deep fascia in abscess for drainage Submandibular incision

54. A hemostat is passed thru the cavity and out the other incision A thin rubber drain is inserted through the wound beaks of the hemostat & withdrawing the Instrument Dressing is placed

55. Ludwig’s angina First described by wilhelm fredreich von ludwig in 1836. Its rapidly spreading in nature Ludwig’s angina is a form of firm, acute, toxic and severe diffuse cellulitis that spreads rapidly, bilaterally, affecting the submandibular , sublingual and submental spaces and resulting in a woody swelling

56. Clinical features Bilateral suprahyoid swelling with hard cardboard like consistency, non fluctuating & painful on palpation Swelling is characterized by rapid onset Difficulty in breathing ( dyspnea ), Difficulty in swallowing ( odynophagia ) Restricted tongue movements, elevated tongue ,inability to open the mouth, salivation Patients may exhibit muffled voice due to edema of vocal apparatus (hot potato voice)

57. Eitiology Odontogenic infections Traumatic injuries Infective conditions like osteomyelitis Pathology: Infection from the source reaches the submandibular space The submental spaces gets involved via the lymphatics It’s a cellulitis it rapidly spreads reaches the epiglottis producing edema and inflammation of laryngeal inlet. Spreads to pterygomandibular , massetric and lateral pharyngeal spaces Patient may die with in 24 hours due asphyxia if not treated May die from septic shock, aspiration of pus or mediastinitis

58. Signs and symptoms: Pyrexic Dehydration Dysphagia Rapid shallow breathing Hoarseness of voice Extra oral features: Hard to firm brawny, board like swellin Skin is shiny stretched and erythmatous Tender swelling with local rise in temperature Unable to close the mouth and drooling of saliva Evident respiratory distress, use of accessory muscle of respiration Trismus Intra oral features: Floor of mouth is raised Tongue appears swollen and raised upwards towards the palate Increased salivation

59. The cardinal signs of Ludwig’s angina are: Bilateral involvement of more than a single deep tissue space Gangrene with serosanguinous , putrid infiltration but little or no frank pus Involvement of connective tissue, fascia, and muscle but not glandular structures Spread via fascial space continuity rather than by lymphatic system Danger signs: Dysapnoea Dysphagia Hoarseness of voice Stridor Swelling below the clavicles

60. Diagnosis & investigations UltraSonography : Used to identify fluid collection in the soft tissues. C.T. Scan M.R.I

61. UltraSonography : Effective diagnostic tool in treatment of acute odontogenic fascial space infections and cellulitis Micro convex probe of 6.5Mhz is used Probe is applied over skin, covering the swelling in transverse and axial sections Echoing of sound from the fluids is absent thereby detecting the fluid collection

62. Differential diagnosis Angioneurotic edema Lingual carcinoma Sub lingual hematoma Salivary Gland abscess Peri-tonsillar abscess

63. Complications Septicemia Carotid blow out Obstruction of upper respiratory airways Aspiration pneumonia Spread of infection into Para pharyngeal spaces- mediastinum -produce thoracic empyema Death due to airway compromise

64. TREATMENT : Early diagnosis of incipient cases Maintenance of patent airway Intense & prolonged antibiotic therapy Extraction of affected teeth Hydration Early surgical drainage

65. “ A chance to cut is a chance to cure ” Classic approach / Cut- throat approach: Horizontal incision midway b/w chin & hyoid bone. Bilateral incision into the submandibular spaces with blunt dissection to the midline Through and through drain or bilateral drains meeting at the midpoint

66. Buccal space infection Buccal space occupies portion of subcutaneous space b/w facial skin & buccinator muscle Maxillary & mandibular premolar and molar teeth tend to drain in lateral & buccal direction Relation of root apices to buccinator muscle determines path of infection : intraorally in buccal vestibule or deeply in buccal space

67. BORDERS: Anterior – corner of mouth Posterior – masseter muscle, pterygomandibular space Superior – maxilla, infraorbital space Inferior – mandible Medial – subcutaneous skin Lateral – buccinator muscle

68. BUCCAL SPACE INFECTION Signs and symptoms: Dome shaped swelling beginning at lower border of mandible extending upwards to level of zygomatic arch Diagnosed because of marked cheek swelling associated with diseased molar/premolar tooth Not associated with trismus

69. Management Intra – oral drainage: Is done with the incision made through the buccinator muscle It is difficult in maintaining a patent opening for drainage because contraction of muscle fibres tend to close it off Hence a horizontal rather than a vertical incision is made just above the depth of the vestibule Extra oral drainage: Inferior to point of fluctuance with blunt dissection Incisions are placed below the lower border of mandible 2 stab incisions are made with a no.11 blade through the skin & subcutaneous tissue A curved hemostat is inserted thru the anterior incision into the buccal space and then turned & exited through the posterior incision Beaks of hemostat are opened, strip of rubber drain is grasped. Hemostat is withdrawn carrying drain through the tissues Ends are fastened, dressing placed

70. Submasseteric space Earliear this space was considered to between masseter and the lateral aspect of the ramus of the mandible. Now it is found to be between three layers of the masseter muscle itself Submasseteric swellings can be differentiated from parotid swellings as these produce marked Trismus overlying masseter muscle Obscure earlobe or elevation of ear lobe in frontal view

71. BORDERS: Anterior– buccal space Posterior – Parotid gland Superior – zygomatic arch Inferior – pterygomassetric sling Medial – ascending ramus of mandible Lateral – masseter muscle Infection can spread from lower third molars Signs and symptoms: External facial swelling confined to masseter muscle Swelling usually does not extend beyond the posterior border of the masseter into the postauricular area Swelling acutely tender Almost complete trismus Overlying skin reddened and stretched Pus may drain at the angle of the mandible

72. Management: Intraorally : Drainage is done through a vertical incision along the ext oblique line of the mandible Starting at the level of the occlusal plane and extending downward & forward in the buccal sulcus to a point opp the second molar A hemostat is inserted and passed posteriorly along the lateral aspect of the ramus to point beneath masseter muscle Beaks are opened Rubber drain is inserted & sutured Extraorally : Incision is made behind the angle of the mandible ( retromandibular incision) Hemostat is inserted and passed along the lateral aspect of the ramus Rubber drain is inserted

73. Pterygomandibular space Most frequently affected anatomical compartment Correlated highly with pericoronitis & mandibular third molar secondary infection results from spread from the sublingual and submandibular spaces Symptoms: Trismus – due to edema & inflamm of med pterygoid Swollen ant tonsillar pillar Deviation of uvula to opposite side

74. Communications: Deep temporal space: By passing around the lateral pterygoid muscle superiorly, running from the mandibular condyle neck and the articular disc to the medial pterygoid plate. Lateral pharyngeal space:by along the anterior border of medial border of medial pterygoid muscle following postereolateral surface of the buccinator and the superior pharyngeal constrictor muscles

75. Rt.Pterygomandibular Space Infection

76. BORDERS: Anteriorly – pterygo mandibular raphae,buccal space Inferior – inf border of mandible upto attachment of medial pterygoid muscle, pterygomassetric sling Superior – Lateral pterygoid muscle Posterior – deep lobe of parotid gland Superficial – lateral pterygoid muscle Deep – ascending ramus of mandible Medially – medial pterygoid muscle Laterally – ascending ramus of the mandible Contents: Inferior alveolar nerve Lingual nerve Nerve to mylohyoid Inferior alveolar artery and vein

77. NOTE : DANGER SPACE 4 IS THE SPACE BETWEEN PREVERTIBRAL AND ALAR FASCIA PTERYGOMANDIBULAR SPACE PTERYGOID SPLEXUS EMISSERY VEINS CAVERNOUS SINUS THROMBOSIS LATERAL PHARYNGEAL SPACE RETROPHARYNGEAL SPACE MEDIASTINUM CAROTID SHEATH DANGER SPACE 4

78. Management Extra oral mandibular block is given Incision is placed through the mucosa in the area b/w medial aspect of the ramus & pterygomandibular raphe . Abscess is opened by blunt dissection and Drain is placed

79. Temporal space Two divisions: Superficial – It is between superficial temporal fascia and lateral aspect of temporalis muscle Deep – It is between the medial surface of the temporalis muscle and periosteum of temporal bone. Inferiorly the temporal space is limited to the attachments of the temporalis muscle and fascia. Inferiorly, it communicates with the pterygomandibular space Its contains loose connective tissue and vessels supplying the temporalis muscle

80. Signs and symptoms: Swelling confined to the shape of the muscle extending from the lateral orbital rim, above the zygomatic arch, covering the lateral aspect of tempral bone. swelling more prominent in a superficial temporal space infection. severe trismus Deep temporal abscess Produce less swelling Lies deep to temporalis muscle Less fluctuant Management: Intra oral sicher’s incision along the anterior border of the ramus of the mandible Extra oral cutaneous incision slightly above the zygomatic arch made parallel to zygomatic arch followed by blunt dissection and placement of drain

81. Lateral pharyngeal space Also known as Pharyngomaxillary / parapharyngeal space Lateral neck space shaped like an inverted cone Base is uppermost at the base of the skull Apex is at the greater horn of the hyoid bone Infections may result from – pharyngitis , tonsilitis , parotitis , otitis , mastoiditis and dental infection

82. Pharyngomaxillary space Suprahyoid superior—skull base Inferior—hyoid Anterior— ptyergomandibular raphe Posterior— prevertebral fascia Medial— buccopharyngeal fascia Lateral—superficial layer of deep fascia Prestyloid Muscular compartment Medial— tonsillar fossa Lateral—medial pterygoid Contains fat, connective tissue, nodes Poststyloid Neurovascular compartment Carotid sheath Cranial nerves IX, X, XI, XII Sympathetic chain Stylopharyngeal aponeurosis of Zuckerkandel and Testut Alar , buccopharyngeal and stylomuscular fascia. Prevents infectious spread from anterior to posterior .

83. Borders: Anterior – sup & middle pharyngeal constrictor muscles Medially – superior constrictor, styloglossus muscle, stylopharyngeus and middle constrictor muscle Posterior – carotid sheath & scalene fascia Superior – skull base Inferior – hyoid bone Superficial – pharyngeal constrictors, retropharyngeal space Deep – medial pterygoid muscle Signs and symptoms: For surgical & anatomical purposes, it is divided into anterior & posterior compartments Ant comp infection pt exhibits pain, fever, chills, medial bulging of lat pharyngeal wall with deviation of palatal uvula from midline, dysphagia , swelling below the angle of the mandible Post comp has absence of trismus & visible swelling, BUT resp obstruction, septic thrombosis of int jugular vein and carotid artery hemorrhage

84. Severe trismus Lateral swelling of the neck Bulging of the lateral pharyngeal wall pushed to midline Usually no extra oral swelling Rapid progression of infection in this space is common Lateral pharyngeal space infection

85. Management Aggressive antibiotic therapy If the mouth can be opened, intra oral incision medial to the anterior border of the ramus Extra orally The incision is placed 1cm below and behind the angle of the mandible. Sinus forceps are inserted into the space between submandibular and parotid gland and passed medial to mandible and upwards along the inner aspect of medial pterygoid muscle.drain is inserted

86. Peritonsillar Space The peritonsillar space consists of loose connective tissue between the capsule of the palatine tonsil and the superior constrictor muscle. The anterior and posterior tonsillar pillars contribute to its anterior and posterior borders, respectively. The posterior tongue forms the inferior boundary. Peritonsillar infections may readily spread to the parapharyngeal space.

87. Quincy

88. Peri-tonsillar space Clinical evaluation: 3-7 days H/o pharyngitis . Severe sore throat, dysphagia , Odyonophagia and referred otalgia . The speech is muffled and classically described as hot potato voice. Trismus is not present In recent literature,needle aspiration instead of open incision and drainage ( JOMS,Vol 51,1993)

89. Parotid Space Formed by the superficial layer of deep cervical fascia surrounding the gland Boundaries : Swelling extends from level of zygomatic above to lower border of mandible Anteriorly it ends at the anterior border of mandible Posteriorly it extends into the retromandibular region

90. Parotid space Superficial layer of deep fascia Dense septa from capsule into gland Direct communication to parapharyngeal space Contains External carotid artery Posterior facial vein Facial nerve Lymph nodes

91. C/F Everted ear lobule Severe pain referred to the ear, accentuated by eating Trismus

92. Spaces of the neck Retropharyngeal space Prevertebral space Mediastinitis

93. Retropharyngeal ,danger space and prevertebral spaces lie between deep cervical fascia the surrounds the pharynx and oesophagus anteriorly and vertebral spine with its muscle attachments posteriorsly

94. Retropharyngeal space Anatomical boundries : anteriorly : constrictor muscles of the neck and their fascia Posteriorly : alar layer of deep cervical fascia which extends from the base of the skull to the superior mediastinum A midline septum exists between the right and left retropharyngeal spaces that is crossed easily. Contents Adenoidal tissues draining posterior pharyngeal wall Lymphnodes draining waldeyers ring

95. Prevertebral space: extends from base of the skull to the coccyx anteriorly bounded by prevertebral fascia For spaces of the neck the infections may arise from nasal, pharyngeal, dental infections

96. Clinical features of space of neck Drooling Fever Irritatibility Nuchal rigidity – neck siffness Irritability light Head ache Dyapnoea Dysphagia Bulging in the posterior pharyngeal wall may be there

97. Dangers involves severe laryngeal edema Rupture of abscess leading to aspiration pnemonia or asphyxia Mediastinitis

98. Management Tracheostomy Extreme trendelburg position Surgical intervention Intra oral: through posterior pharyngeal wall Extra oral: inferior to hyoid parallel to sternocleidomastoid , retraction of muscle and carotid sheath, blunt dissection till hypopharynx . Deep dissection to carotid sheath between it and inferior constrictor muscles rupture retropharyngeal abscess Deep drains inserted

99. Principles in Treatment of Oral and Paraoral Infections Remove the cause. Establish drainage. Institute antibiotic therapy. Supportive care, including proper rest and nutrition.

100. Management of Odontogenic Infections General principles Goals of management of odontogenic infection: Airway protection Surgical drainage Medical support of the patient Identification of etiologic bacteria Selection of appropriate antibiotic therapy

101. Airway protection Floor of mouth and tongue elevation or narrowing can cause respiratory distress Expedient assessment and diagnosis of airway compromise is the most important initial step in managing odontogenic infections Airway loss is primary cause of death in these patients

102. Initially intact airway must be continuously reevaluated during treatment Signs and findings of airway compromise: inability to assume a supine position, stridor , and restlessness etc. Surgeon must decide the need, timing and method to establish an emergency airway

103. Surgical drainage Administration of intravenous antibiotics without drainage of pus may not allow for resolution of an abscess Starting antibiotic therapy without Gram's stain and cultures may result in failure to identify pathogens Important to drain all primary spaces as well as explore and drain potentially involved secondary spaces

104. CT scans may help identifying spaces involved Panorex can help identify putative teeth involved

105. Canine, sublingual and vestibular abscesses are drained intraorally Masseteric , pterygomandibular , and lateral pharyngeal space abscesses can be drained with combination intraoral and extraoral drainage Temporal, submandibular , submental , retropharyngeal, and buccal space abscesses may mandate extraoral incision and drainage

106. Technique: Small incision are made in a dependent area Placement of a hemostat in the abscess cavity with entry into all loculations of the abscess drains inserted into cavity to allow for postoperative drainage of the abscess

107. PURPOSES OF SURGICAL DRAINAGE & INCISION Rid the body of toxic purulent material Decompress the tissues Allowing better perfusion of blood containing antibiotics and defensive elements Increased oxygenation of the infected area

108. Dependent drainage of the space is performed by placing a horizontal incision in the most dependent area of the swelling extraorally / intraorally with a cosmetic scar being the result

109. Medical support of the patient Rehydrate patient as dehydration may be present Treat conditions that predispose patient to infection (DM) Oral pain, trismus , and swelling can be addressed by appropriate analgesia and treatment of underlying infection

110. Identification of etiologic bacteria Expected causes are alpha hemolytic streptococci and oral anaerobes Cultures should be performed on all patients undergoing incision and drainage and sensitivities ordered if patient is not progressing well (possible antibiotic resistance) An aspirate of the abscess can be performed and sent for culture and sensitivities if incision and drainage delayed

111. Antibiotic Therapy Removal of the cause, drainage, and supportive care more important than antibiotic therapy. Infections are cured by the patient’s defenses, not antibiotics. Risks of allergy, toxicity, side effects, resistance and superinfection causing serious or potentially fatal consequences must be considered .

112. Principles of antibiotic use – Necessity – Empirical therapy – Narrow spectrum – Low toxicity – Bacteriocidal – Administer properly – Cost

113. Antibiotic therapy, con’t. Oral infections are typically polymicrobial . Antibiotic effectiveness dependent upon adequate tissue (not serum) concentration for an appropriate amount of time. Antibiotics should be prescribed for at least one week – adequate tissue concentration achieved in 24-48 hours, with bacteriocidal activity occurring over the next 3-5 days.

114. EMPIRIC ANTIBIOTIC TREATMENT Modified from Flynn TR. The swollen face. Severe odontogenic infections.Emerg Med Clin N Am 2000;18: Early infection (first 3 days of symptoms or mildly immunocompromised ) Penicillin Clindamycin Cephalexin (or other first-generation cephalosporin)

115. Late infection (after 3 days of symptoms or moderately to severely immunocompromised ) Clindamycin (maximum dose) Penicillin and metronidazole Ampicillin and sulbactam Cephalosporin (first or second generation) Mild, moderate, and severe compromise is based on CD4/viral loads, glycemic control, and the degree of alcoholic related disease.

116. Antibiotic therapy, con’t . Penicillin ( bacteriocidal ) drug of choice for treatment of odontogenic infections (5% incident of allergy). Clindamycin ( bactericiodal ) 1 st line after penicillin; effective against anaerobes; Cephalosporin (slightly broader spectrum and bacteriocidal ); cautious use in penicillin-allergic patients → cross-sensitivity; if history of anaphylaxis to penicillin, do not use.

117. Antibiotic therapy, con’t . Erythromycin ( bacteriostatic ) good 2 nd line drug after penicillin; use enteric-coated to reduce GI upset. Metronidazole ( bacteriocidal ) excellent against anaerobes only. Augmentin (amoxicillin + clavulanic acid) kills penicillinase -producing bacteria that interferes with amoxicillin; expensive.

118. Selection of antibiotic therapy Penicillin Metronidazole in combination with penicillin can be used in severe infections Clindamycin for penicillin-allergic patients Causes for clinical failure include inadequate drainage or antibiotic resistance

119. COMPLICATIONS Brain Abscess : Etiology – bacteremia accompanying any odontogenic infection C/F – headache, nausea, vomiting, Other symptoms : hemiplegia , pappiloedema , aphasia, convulsions, hemisensory deficit

120. Drug Therapy – antibiotics & steroids Mannitol to reduce to edema Chloramphenicol ; antibiotic of choice Surgery to provide drainage

121. MENINGITIS Most common neurological complication C/F : headache, fever, stiffness of neck & vomiting Kernig’s sign – passive resistance to extend the knee from flexed thigh position Brudzinski’s sign – abrupt neck flexion in supine resulting in involuntary flexion of knees Diagnosis : lumbar puncture

122. Rx : chloramphinicol + penicillin G Hydration Electrolyte balance Control of cerebral edema Avoidance of vascular collapse and shock

123. MEDIASTINITIS Late complication due to delayed diagnosis & inadequate surgical drainage It is a descending cervical cellulitis that arises from submandibular space infection, parapharyngeal space, pterygomandibular space or buccal space

124. S/S : unremitting high fever, tachycardia, tachypnoea & hypotension Brawny edema, induration of neck n chest and crepitus may be palpable Rx :early recognition , airway control, agg surgical intervention ( transthoracic or cervicomediastinal approach), app antibiotic therapy, supportive systemic care & hyperbaric oxygen therapy

125. CAVERNOUS SINUS THROMBOPHLEBITIS : External route – danger area of face Internal route – odontogenic infection from post maxillary region through pterygoid plexus C/F : Initial – swelling of face with involvement of eyelids Pulsating exopthalmos

126. Cranial nerve involvement ( oculomotor , trochlear , abducens , opthalmic & carotid sympathetic plexus) Late – thrombophlebitis Advanced – toxaemia , meningitis, + Kernig’s sign and brudzinski’s sign Septicimia

127. Rx : antibiotic therapy Heparinization – heparin 20,000 units in 1500ml off 5% dextrose or Dicumarol 200mg Neurosurgical consultation Mannitol Anticoagulants Surgical drainage

128. Early recognition of orofacial infection and prompt , appropriate therapy is absolutely necessary A thorough knowledge of anatomy of the face and neck is necessary to predict pathways of spread and to drain these spaces adequately

129. THANK YOU

130. REFERENCES: Topazian , Oral & maxillofacial infections , Vol 4 Daniel M Laskin , text book of oral & maxillofacial surgery vol II Peterson ,text book of oral & maxillofacial surgery Neelima malik , text book of oral & maxillofacial surgery

131. Fasciae of head and neck